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Kaiser Permanente Medicare Plus Std w/Part D (AB) (Cost) (H2150-009-0)
Tier 1 (142)
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Tier 3 (309)
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2019 Medicare Part D Plan Formulary Information
Kaiser Permanente Medicare Plus Std w/Part D (AB) (Cost) (H2150-009-0)
Benefit Details           
The Kaiser Permanente Medicare Plus Std w/Part D (AB) (Cost) (H2150-009-0)
Formulary Drugs Starting with the Letter A

in Fairfax County, VA: CMS MA Region 7 which includes: VA
Plan Monthly Premium: $36.00 Deductible: $240
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
ABACAVIR 20 MG/ML SOLUTION   2* Generic $15.00$30.00None
ABACAVIR 300 MG TABLET   2* Generic $15.00$30.00None
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   2* Generic $15.00$30.00None
ABACAVIR-LAMIVUDINE 600-300 MG   2* Generic $15.00$30.00None
ABELCET INJECTION SUSPENSION 5MG/ML   4 Non-Preferred Brand $95.00$190.00None
ABILIFY 10MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ABILIFY 15MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ABILIFY 20MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ABILIFY 2MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ABILIFY 30MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 5 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ABILIFY MAINTENA ER 300 MG SYR   4 Non-Preferred Brand $95.00$190.00None
ABILIFY MAINTENA ER 300 MG VL   4 Non-Preferred Brand $95.00$190.00None
ABILIFY MAINTENA ER 400 MG SUSER VIAL   4 Non-Preferred Brand $95.00$190.00None
ABILIFY MAINTENA ER 400 MG SYR   4 Non-Preferred Brand $95.00$190.00None
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   5* Specialty Tier 25%25%None
ABSORICA 10 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
ABSORICA 20 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
ABSORICA 25 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
ABSORICA 30 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
ABSORICA 35 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABSORICA 40 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
ABSTRAL 100 MCG TAB SUBLINGUAL   4 Non-Preferred Brand $95.00$190.00P
ABSTRAL 200 MCG TAB SUBLINGUAL   4 Non-Preferred Brand $95.00$190.00P
ABSTRAL 300 MCG TAB SUBLINGUAL   4 Non-Preferred Brand $95.00$190.00P
ABSTRAL 400 MCG TAB SUBLINGUAL   4 Non-Preferred Brand $95.00$190.00P
ABSTRAL 600 MCG TAB SUBLINGUAL   4 Non-Preferred Brand $95.00$190.00P
ABSTRAL 800 MCG TAB SUBLINGUAL   4 Non-Preferred Brand $95.00$190.00P
Acamprosate Calcium DR 333 MG tablets [Campral]   2* Generic $15.00$30.00None
ACANYA 25; 10mg/g; mg/g 1 BOTTLE, PUMP per CARTON / 50 g in 1 BOTTLE, PUMP   2* Generic $15.00$30.00None
ACARBOSE 100 MG TABLET   2* Generic $15.00$30.00None
ACARBOSE 25 MG TABLET   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACARBOSE 50 MG TABLET   2* Generic $15.00$30.00None
ACCOLATE 10 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACCOLATE 20 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACCUPRIL 10MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACCUPRIL 20MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACCUPRIL 40MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACCUPRIL 5MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACCURETIC 10-12.5MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACCURETIC 20-12.5MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACCURETIC 20-25MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACEBUTOLOL 200 MG CAPSULE   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACEBUTOLOL 400 MG CAPSULE   2* Generic $15.00$30.00None
ACETAMINOP-CODEINE 120-12 MG/5   2* Generic $15.00$30.00None
Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Lorcet]   2* Generic $15.00$30.00None
ACETAMINOPHEN-COD #2 TABLET   2* Generic $15.00$30.00None
ACETAMINOPHEN-COD #3 TABLET   2* Generic $15.00$30.00None
ACETAMINOPHEN-COD #4 TABLET   2* Generic $15.00$30.00None
ACETAZOLAMIDE 125MG TABLET   2* Generic $15.00$30.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   2* Generic $15.00$30.00None
ACETAZOLAMIDE ER 500 MG CAP   2* Generic $15.00$30.00None
ACETIC ACID 2% EAR SOLUTION   2* Generic $15.00$30.00None
ACETYLCYSTEINE 10% VIAL   2* Generic $15.00$30.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acetylcysteine 200 MG/ML Inhalant Solution   2* Generic $15.00$30.00P
ACIPHEX 20MG TABLET EC   4 Non-Preferred Brand $95.00$190.00None
ACITRETIN 10 MG CAPSULE [Soriatane]   2* Generic $15.00$30.00None
ACITRETIN 17.5 MG CAPSULE [Soriatane]   2* Generic $15.00$30.00None
ACITRETIN 25 MG CAPSULE [Soriatane]   2* Generic $15.00$30.00None
ACTEMRA 162 MG/0.9 ML SYRINGE   5* Specialty Tier 25%25%None
ACTEMRA ACTPEN 162 MG/0.9 ML PEN INJCTR   5* Specialty Tier 25%25%None
ACTHIB VACCINE WITH DILUENT   6* Vaccines $0.00N/ANone
ACTIGALL 300 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
ACTIMMUNE 100 MCG/0.5 ML VIAL   4 Non-Preferred Brand $95.00$190.00None
ACTIQ 1200MCG LOZENGE   5* Specialty Tier 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTIQ 1600MCG LOZENGE   5* Specialty Tier 25%25%P
ACTIQ 200MCG LOZENGE   4 Non-Preferred Brand $95.00$190.00P
ACTIQ 400MCG LOZENGE   5* Specialty Tier 25%25%P
ACTIQ 600MCG LOZENGE   5* Specialty Tier 25%25%P
ACTIQ 800MCG LOZENGE   5* Specialty Tier 25%25%P
ACTIVELLA 0.5-0.1 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACTIVELLA 1 MG-0.5 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACTONEL 150 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACTONEL 35 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACTONEL 5 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACTOPLUS MET 15MG/500MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOPLUS MET 15MG/850MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACTOS 15 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACTOS 30 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACTOS 45 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ACULAR 0.5% EYE DROPS   4 Non-Preferred Brand $95.00$190.00None
ACULAR LS 0.4% OPHTH SOL   4 Non-Preferred Brand $95.00$190.00None
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA   4 Non-Preferred Brand $95.00$190.00None
ACYCLOVIR 200 MG CAPSULE   2* Generic $15.00$30.00None
ACYCLOVIR 200 MG/5 ML SUSP   2* Generic $15.00$30.00None
ACYCLOVIR 400 MG TABLET   2* Generic $15.00$30.00None
ACYCLOVIR 5% CREAM (g) [Zovirax]   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acyclovir 5% Ointment   2* Generic $15.00$30.00None
ACYCLOVIR 800 MG TABLET   2* Generic $15.00$30.00None
Acyclovir sodium 500 mg vial   2* Generic $15.00$30.00None
ACZONE 5% GEL   4 Non-Preferred Brand $95.00$190.00None
ADACEL TDAP SYRINGE   6* Vaccines $0.00N/ANone
ADACEL VIAL 2UNT/5UNT   6* Vaccines $0.00N/ANone
ADALAT CC 30 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ADALAT CC 60 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ADALAT CC 90 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5* Specialty Tier 25%25%None
ADAPALENE 0.1% CREAM   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADAPALENE 0.1% GEL   2* Generic $15.00$30.00None
ADAPALENE 0.1% SOLUTION [Plixda]   5* Specialty Tier 25%25%None
ADAPALENE 0.1% SWAB MED. SWAB [Plixda]   2* Generic $15.00$30.00None
Adapalene 0.3% gel   2* Generic $15.00$30.00None
ADAPALENE-BNZYL PEROX 0.1-2.5% [EPIDUO]   2* Generic $15.00$30.00None
ADCIRCA TABLETS 20MG 60 BOTTLE   5* Specialty Tier 25%25%P
ADDERALL 20 MG TABLET   2* Generic $15.00$30.00None
ADDERALL 5 MG TABLET   2* Generic $15.00$30.00None
ADDERALL 7.5 MG TABLET   2* Generic $15.00$30.00None
ADDERALL XR 10MG CAPSULE SA   2* Generic $15.00$30.00None
ADDERALL XR 15MG CAPSULE SA   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADDERALL XR 20MG CAPSULE SA   2* Generic $15.00$30.00None
ADDERALL XR 25MG CAPSULE SA   2* Generic $15.00$30.00None
ADDERALL XR 30MG CAPSULE SA   2* Generic $15.00$30.00None
ADDERALL XR 5MG CAPSULE SA   2* Generic $15.00$30.00None
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]   2* Generic $15.00$30.00None
ADEMPAS 0.5 MG TABLET   5* Specialty Tier 25%25%P
ADEMPAS 1 MG TABLET   5* Specialty Tier 25%25%P
ADEMPAS 1.5 MG TABLET   5* Specialty Tier 25%25%P
ADEMPAS 2 MG TABLET   5* Specialty Tier 25%25%P
ADEMPAS 2.5 MG TABLET   5* Specialty Tier 25%25%P
ADLYXIN 10-20 MCG STARTER PACK   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADLYXIN 20 MCG MAINTENANCE PK   4 Non-Preferred Brand $95.00$190.00None
ADMELOG 100 UNIT/ML VIAL [Humalog]   4 Non-Preferred Brand $95.00$190.00None
ADMELOG SOLOSTAR 100 UNIT/ML INSULN PEN [Humalog KwikPen]   4 Non-Preferred Brand $95.00$190.00None
ADVAIR DISKUS MIS 100/50   3* Preferred Brand $42.00$84.00None
ADVAIR DISKUS MIS 250/50   3* Preferred Brand $42.00$84.00None
ADVAIR DISKUS MIS 500/50   3* Preferred Brand $42.00$84.00None
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3* Preferred Brand $42.00$84.00None
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3* Preferred Brand $42.00$84.00None
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3* Preferred Brand $42.00$84.00None
ADZENYS ER 1.25 MG/ML SUSP BP 24H   4 Non-Preferred Brand $95.00$190.00None
ADZENYS XR-ODT 12.5 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADZENYS XR-ODT 15.7 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ADZENYS XR-ODT 18.8 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ADZENYS XR-ODT 3.1 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ADZENYS XR-ODT 6.3 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ADZENYS XR-ODT 9.4 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5* Specialty Tier 25%25%None
AFINITOR DISPERZ 2 MG TABLET   5* Specialty Tier 25%25%None
AFINITOR DISPERZ 3 MG TABLET   5* Specialty Tier 25%25%None
AFINITOR DISPERZ 5 MG TABLET   5* Specialty Tier 25%25%None
AFINITOR TABLETS 10 MG   5* Specialty Tier 25%25%None
AFINITOR TABLETS 2.5 MG   5* Specialty Tier 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR TABLETS 5 MG   5* Specialty Tier 25%25%None
AFREZZA 12 UNIT CARTRIDGE CART INHAL   4 Non-Preferred Brand $95.00$190.00None
AFREZZA 4 UNIT/8 UNIT/12 UNIT   4 Non-Preferred Brand $95.00$190.00None
AFREZZA 4 UNITS CARTRIDGE INH   4 Non-Preferred Brand $95.00$190.00None
AFREZZA 8 UNIT CARTRIDGE CART INHAL   4 Non-Preferred Brand $95.00$190.00None
AFREZZA 90-4 UNIT / 90-8 UNIT   4 Non-Preferred Brand $95.00$190.00None
AFREZZA 90-8 UNIT / 90-12 UNIT CART INHAL   5* Specialty Tier 25%25%None
AGGRENOX 25-200MG CAPSULE   2* Generic $15.00$30.00None
AGRYLIN 0.5MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
AIMOVIG 140 MG/ML AUTOINJECTOR   4 Non-Preferred Brand $95.00$190.00None
AIMOVIG 70 MG/ML AUTOINJECTOR   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AIRDUO RESPICLICK 113-14 MCG   4 Non-Preferred Brand $95.00$190.00None
AIRDUO RESPICLICK 232-14 MCG   4 Non-Preferred Brand $95.00$190.00None
AIRDUO RESPICLICK 55-14 MCG   4 Non-Preferred Brand $95.00$190.00None
AJOVY 225 MG/1.5 ML SYRINGE   4 Non-Preferred Brand $95.00$190.00None
AKTIPAK 3%-5% GEL POUCH   4 Non-Preferred Brand $95.00$190.00None
Ala-cort 2.5% cream   2* Generic $15.00$30.00None
ALA-SCALP HP 2% LOTION   2* Generic $15.00$30.00None
ALBENDAZOLE 200 MG TABLET [Albenza]   2* Generic $15.00$30.00None
ALBENZA 200 MG TABLET   5* Specialty Tier 25%25%None
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   4 Non-Preferred Brand $95.00$190.00None
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   2* Generic $15.00$30.00None
ALBUTEROL SUL 2.5 MG/3 ML SOLN   1* Preferred Generic $7.00$0.00P
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   2* Generic $15.00$30.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2* Generic $15.00$30.00P
ALBUTEROL SULFATE 2 MG TAB   2* Generic $15.00$30.00None
ALBUTEROL SULFATE 4 MG TAB   2* Generic $15.00$30.00None
ALBUTEROL SULFATE 4MG TABLET SR 12HR   2* Generic $15.00$30.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   2* Generic $15.00$30.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1* Preferred Generic $7.00$0.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   2* Generic $15.00$30.00None
ALCLOMETASONE DIPR 0.05% OINT   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCLOMETASONE DIPRO 0.05% CRM   2* Generic $15.00$30.00None
ALDACTAZIDE 25/25 TABLET   4 Non-Preferred Brand $95.00$190.00None
ALDACTAZIDE 50/50 TABLET   4 Non-Preferred Brand $95.00$190.00None
ALDACTONE 100MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ALDACTONE 25MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ALDACTONE 50MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ALDARA 5% CREAM   4 Non-Preferred Brand $95.00$190.00None
ALECENSA 150 MG CAPSULE   5* Specialty Tier 25%25%None
ALENDRONATE SODIUM 10 MG TAB   1* Preferred Generic $7.00$0.00None
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1* Preferred Generic $7.00$0.00None
ALENDRONATE SODIUM 40 MG TABLET   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 5 MG TABLET   1* Preferred Generic $7.00$0.00None
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1* Preferred Generic $7.00$0.00None
ALENDRONATE SODIUM 70 MG/75 ML   2* Generic $15.00$30.00None
ALFUZOSIN HCL ER 10 MG TABLET   2* Generic $15.00$30.00None
ALINIA 100 MG/5 ML SUSPENSION   3* Preferred Brand $42.00$84.00None
ALINIA 500 MG TABLET   3* Preferred Brand $42.00$84.00None
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Brand $95.00$190.00None
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Brand $95.00$190.00None
ALISKIREN 150 MG TABLET [Tekturna]   2* Generic $15.00$30.00None
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Brand $95.00$190.00None
ALISKIREN 300 MG TABLET [Tekturna]   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL 100 MG TABLET   2* Generic $15.00$30.00None
ALLOPURINOL 300 MG TABLET   2* Generic $15.00$30.00None
ALLZITAL 25-325 MG TABLET   2* Generic $15.00$30.00None
ALMOTRIPTAN MALATE 12.5 MG TAB [Axert]   2* Generic $15.00$30.00None
ALMOTRIPTAN MALATE 6.25 MG TAB [Axert]   2* Generic $15.00$30.00None
ALOCRIL 2% EYE DROPS   4 Non-Preferred Brand $95.00$190.00None
ALOGLIPTIN 12.5 MG TABLET [Nesina]   2* Generic $15.00$30.00None
ALOGLIPTIN 25 MG TABLET [Nesina]   2* Generic $15.00$30.00None
ALOGLIPTIN 6.25 MG TABLET [Nesina]   2* Generic $15.00$30.00None
ALOGLIPTIN-METFORMIN 12.5-1000 [Kazano]   2* Generic $15.00$30.00None
ALOGLIPTIN-METFORMIN 12.5-500 [Kazano]   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALOGLIPTIN-PIOGLIT 12.5-15 MG [Oseni]   2* Generic $15.00$30.00None
ALOGLIPTIN-PIOGLIT 12.5-30 MG [Oseni]   2* Generic $15.00$30.00None
ALOGLIPTIN-PIOGLIT 12.5-45 MG [Oseni]   2* Generic $15.00$30.00None
ALOGLIPTIN-PIOGLIT 25-15 MG TABLET [Oseni]   2* Generic $15.00$30.00None
ALOGLIPTIN-PIOGLIT 25-30 MG TABLET [Oseni]   2* Generic $15.00$30.00None
ALOGLIPTIN-PIOGLIT 25-45 MG TABLET [Oseni]   2* Generic $15.00$30.00None
ALOMIDE 0.1% EYE DROPS   4 Non-Preferred Brand $95.00$190.00None
ALORA 0.025 MG PATCH TDSW [Vivelle-Dot]   4 Non-Preferred Brand $95.00$190.00None
ALORA 0.05 MG PATCH   4 Non-Preferred Brand $95.00$190.00None
ALORA 0.075 MG PATCH   4 Non-Preferred Brand $95.00$190.00None
ALORA 0.1 MG PATCH   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   2* Generic $15.00$30.00None
ALOSETRON HCL 1 MG TABLET [Lotronex]   2* Generic $15.00$30.00None
ALPHAGAN P 0.1% DROPS   4 Non-Preferred Brand $95.00$190.00None
ALPHAGAN P 0.15% EYE DROPS   4 Non-Preferred Brand $95.00$190.00None
ALPRAZOLAM 0.25 MG TABLET   2* Generic $15.00$30.00None
ALPRAZOLAM 0.5 MG TABLET   2* Generic $15.00$30.00None
ALPRAZOLAM 1 MG TABLET   2* Generic $15.00$30.00None
Alprazolam 1mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   2* Generic $15.00$30.00None
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE   2* Generic $15.00$30.00None
ALPRAZOLAM 2 MG TABLET   2* Generic $15.00$30.00None
Alprazolam 2mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALPRAZOLAM ER 0.5 MG TABLET   2* Generic $15.00$30.00None
ALPRAZOLAM ER 1 MG TABLET   2* Generic $15.00$30.00None
ALPRAZOLAM ER 2 MG TABLET   2* Generic $15.00$30.00None
ALPRAZOLAM ER 3 MG TABLET   2* Generic $15.00$30.00None
ALPRAZOLAM ODT 0.25 MG TABLET   2* Generic $15.00$30.00None
ALPRAZOLAM ODT 0.5 MG TABLET   2* Generic $15.00$30.00None
ALREX 0.2% EYE DROPS   4 Non-Preferred Brand $95.00$190.00None
ALTACE 1.25MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
ALTACE 10MG CAPSULE (100 CT)   4 Non-Preferred Brand $95.00$190.00None
ALTACE 2.5 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
ALTACE 5MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALTAVERA-28 TABLET [Portia]   2* Generic $15.00$30.00None
ALTOPREV 20 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ALTOPREV 60 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ALTRENO 0.05% LOTION   4 Non-Preferred Brand $95.00$190.00None
ALUNBRIG 180 MG TABLET   5* Specialty Tier 25%25%None
ALUNBRIG 30 MG TABLET   5* Specialty Tier 25%25%None
ALUNBRIG 90 MG TABLET   5* Specialty Tier 25%25%None
ALUNBRIG 90 MG-180 MG TABLET PACK   5* Specialty Tier 25%25%None
ALVESCO 160 MCG INHALER HFA AER AD   3* Preferred Brand $42.00$84.00None
ALVESCO 80 MCG INHALER HFA AER AD   3* Preferred Brand $42.00$84.00None
ALYACEN 1-35-28 TABLET   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALYQ 20 MG TABLET   2* Generic $15.00$30.00P
Amabelz 0.5 MG/0.1 MG 28 TABLET/BLISTER PACK 3 PER CARTON   2* Generic $15.00$30.00None
Amabelz 1 MG/0.5 MG 28 TABLET/BLISTER PACK 3 PER CARTON   2* Generic $15.00$30.00None
AMANTADINE 100 MG CAPSULE   2* Generic $15.00$30.00None
AMANTADINE 100 MG TABLET   2* Generic $15.00$30.00None
AMANTADINE 50 MG/5 ML SOLUTION   2* Generic $15.00$30.00None
AMARYL 1MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AMARYL 2MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AMARYL 4MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AMBIEN 10 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AMBIEN CR 12.5MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBIEN CR 6.25MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AMBIEN TABLETS 5MG 100 BOTTLE   4 Non-Preferred Brand $95.00$190.00None
AMBISOME 50MG VIAL   5* Specialty Tier 25%25%None
AMBRISENTAN 10 MG TABLET [LETAIRIS]   2* Generic $15.00$30.00None
AMBRISENTAN 5 MG TABLET [LETAIRIS]   2* Generic $15.00$30.00None
AMCINONIDE 0.1% CREAM   2* Generic $15.00$30.00None
AMCINONIDE 0.1% LOTION   2* Generic $15.00$30.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   2* Generic $15.00$30.00None
AMERGE 1MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AMERGE 2.5MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AMETHIA 0.15-0.03-0.01 MG TABLET   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMETHIA LO TABLET   2* Generic $15.00$30.00None
AMIKACIN SULF 500 MG/2 ML VIAL   2* Generic $15.00$30.00None
AMILORIDE HCL 5 MG TABLET [Midamor]   2* Generic $15.00$30.00None
AMILORIDE HCL-HCTZ 5-50 MG TABLET   1* Preferred Generic $7.00$0.00None
Amino Acids 15% Solution   2* Generic $15.00$30.00None
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10]   3* Preferred Brand $42.00$84.00None
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5]   3* Preferred Brand $42.00$84.00None
Amino acids 4.25% with electrolytes in dextrose 10% Injectable Solution [Clinimix E 4.25/10]   3* Preferred Brand $42.00$84.00None
AMINOSYN II 10% SOL 6X2000 ML   4 Non-Preferred Brand $95.00$190.00None
AMINOSYN II 15% IV SOLUTION   4 Non-Preferred Brand $95.00$190.00None
AMINOSYN PF INJECTION   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Brand $95.00$190.00None
AMIODARONE HCL 100 MG TABLET   2* Generic $15.00$30.00None
AMIODARONE HCL 200 MG TABLET   2* Generic $15.00$30.00None
AMIODARONE HCL 400 MG TABLET   2* Generic $15.00$30.00None
AMITIZA 8MCG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
AMITIZA CAPSULES 24MCG 60 CAP BOT   4 Non-Preferred Brand $95.00$190.00None
AMITRIP/CDP 25-10 TABLET   2* Generic $15.00$30.00None
AMITRIP/PERPHEN 10-4 TABLET   2* Generic $15.00$30.00None
AMITRIP/PERPHEN 50-4 TABLET   2* Generic $15.00$30.00None
AMITRIPTYLINE HCL 10 MG TAB   2* Generic $15.00$30.00None
AMITRIPTYLINE HCL 100 MG TAB   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 150 MG TAB   2* Generic $15.00$30.00None
AMITRIPTYLINE HCL 25 MG TAB   2* Generic $15.00$30.00None
AMITRIPTYLINE HCL 50 MG TAB   2* Generic $15.00$30.00None
AMITRIPTYLINE HCL 75 MG TAB   2* Generic $15.00$30.00None
AMLOD-VALSA-HCTZ 10-160-12.5MG [Exforge HCT]   2* Generic $15.00$30.00None
AMLOD-VALSA-HCTZ 10-160-25 MG [Exforge HCT]   2* Generic $15.00$30.00None
AMLOD-VALSA-HCTZ 10-320-25 MG [Exforge HCT]   2* Generic $15.00$30.00None
AMLOD-VALSA-HCTZ 5-160-12.5 MG [Exforge HCT]   2* Generic $15.00$30.00None
AMLOD-VALSA-HCTZ 5-160-25 MG [Exforge HCT]   2* Generic $15.00$30.00None
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1* Preferred Generic $7.00$0.00None
AMLODIPINE BESYLATE 2.5 MG TAB   1* Preferred Generic $7.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1* Preferred Generic $7.00$0.00None
AMLODIPINE-ATORVAST 10-20 MG [Caduet]   2* Generic $15.00$30.00None
AMLODIPINE-ATORVAST 10-40 MG [Caduet]   2* Generic $15.00$30.00None
Amlodipine-Atorvastatin 10-10 mg [Caduet]   2* Generic $15.00$30.00None
Amlodipine-Atorvastatin 10-80 mg [Caduet]   2* Generic $15.00$30.00None
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   2* Generic $15.00$30.00None
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   2* Generic $15.00$30.00None
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   2* Generic $15.00$30.00None
Amlodipine-Atorvastatin 5-10 mg [Caduet]   2* Generic $15.00$30.00None
Amlodipine-Atorvastatin 5-20 mg [Caduet]   2* Generic $15.00$30.00None
Amlodipine-Atorvastatin 5-40 mg [Caduet]   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amlodipine-Atorvastatin 5-80 mg [Caduet]   2* Generic $15.00$30.00None
AMLODIPINE-BENAZEPRIL 10-20 MG Capsule [Lotrel]   2* Generic $15.00$30.00None
AMLODIPINE-BENAZEPRIL 10-40 MG Capsule [Lotrel]   2* Generic $15.00$30.00None
AMLODIPINE-BENAZEPRIL 2.5-10 Capsule [Lotrel]   2* Generic $15.00$30.00None
AMLODIPINE-BENAZEPRIL 5-10 MG Capsule [Lotrel]   2* Generic $15.00$30.00None
AMLODIPINE-BENAZEPRIL 5-20 MG Capsule [Lotrel]   2* Generic $15.00$30.00None
AMLODIPINE-BENAZEPRIL 5-40 MG Capsule [Lotrel]   2* Generic $15.00$30.00None
AMLODIPINE-OLMESARTAN 10-20 MG [Azor]   2* Generic $15.00$30.00None
AMLODIPINE-OLMESARTAN 10-40 MG [Azor]   2* Generic $15.00$30.00None
AMLODIPINE-OLMESARTAN 5-20 MG [Azor]   2* Generic $15.00$30.00None
AMLODIPINE-OLMESARTAN 5-40 MG [Azor]   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-VALSARTAN 10-160 MG   2* Generic $15.00$30.00None
AMLODIPINE-VALSARTAN 10-320 MG   2* Generic $15.00$30.00None
AMLODIPINE-VALSARTAN 5-160 MG   2* Generic $15.00$30.00None
AMLODIPINE-VALSARTAN 5-320 MG   2* Generic $15.00$30.00None
AMMONIUM LACTATE 12% CREAM   2* Generic $15.00$30.00None
AMMONIUM LACTATE 12% LOTION   2* Generic $15.00$30.00None
AMNESTEEM 10 MG CAPSULE   2* Generic $15.00$30.00None
AMNESTEEM 20 MG CAPSULE   2* Generic $15.00$30.00None
AMNESTEEM 40 MG CAPSULE   2* Generic $15.00$30.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   2* Generic $15.00$30.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   2* Generic $15.00$30.00None
AMOX-CLAV 200-28.5 MG/5 ML SUS   2* Generic $15.00$30.00None
AMOX-CLAV 250-62.5 MG/5 ML SUS   2* Generic $15.00$30.00None
AMOX-CLAV 400-57 MG/5 ML SUSP   2* Generic $15.00$30.00None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2* Generic $15.00$30.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2* Generic $15.00$30.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2* Generic $15.00$30.00None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   2* Generic $15.00$30.00None
AMOXAPINE 100MG TABLET   2* Generic $15.00$30.00None
AMOXAPINE 150MG TABLET   2* Generic $15.00$30.00None
AMOXAPINE 25MG TABLET   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 50MG TABLET   2* Generic $15.00$30.00None
AMOXICILLIN 125 MG/5 ML SUSP   2* Generic $15.00$30.00None
AMOXICILLIN 125MG TABLET CHEW   2* Generic $15.00$30.00None
AMOXICILLIN 200 MG/5 ML SUSP   2* Generic $15.00$30.00None
AMOXICILLIN 250 MG CAPSULE   2* Generic $15.00$30.00None
AMOXICILLIN 250 MG TAB CHEW   2* Generic $15.00$30.00None
AMOXICILLIN 250 MG/5 ML SUSP   2* Generic $15.00$30.00None
AMOXICILLIN 400 MG/5 ML SUSP   2* Generic $15.00$30.00None
AMOXICILLIN 500 MG CAPSULE   2* Generic $15.00$30.00None
AMOXICILLIN 500 MG TABLET   2* Generic $15.00$30.00None
AMOXICILLIN 875 MG TABLET   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 12.5MG TABLET   2* Generic $15.00$30.00None
AMPHETAMINE SALT COMBO 15MG TABLET   2* Generic $15.00$30.00None
AMPHETAMINE SALT COMBO 7.5MG TABLET   2* Generic $15.00$30.00None
AMPHETAMINE SALTS 5 MG TAB   2* Generic $15.00$30.00None
AMPHETAMINE SULFATE 10 MG TABLET [Evekeo]   2* Generic $15.00$30.00None
AMPHETAMINE SULFATE 5 MG TABLET [Evekeo]   2* Generic $15.00$30.00None
amphotericin b 50mg/10mL 10 mL in 1 VIAL   2* Generic $15.00$30.00None
AMPICILLIN 10 GM VIAL   2* Generic $15.00$30.00None
Ampicillin 1000 MG / Sulbactam 500 MG Injection   2* Generic $15.00$30.00None
Ampicillin 1000 MG Injection   2* Generic $15.00$30.00None
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Ampicillin 2000 MG / Sulbactam 1000 MG Injection   2* Generic $15.00$30.00None
AMPICILLIN CAPSULES 500MG 100 BOT   2* Generic $15.00$30.00None
AMPICILLIN-SULBACTAM 15 GM VL   2* Generic $15.00$30.00None
AMPYRA ER 10 MG TABLET   5* Specialty Tier 25%25%None
AMRIX 30 MG   4 Non-Preferred Brand $95.00$190.00P
AMRIX CAPSULES EXTENDED RELEASE 15MG 60 CAPSULES BOT   4 Non-Preferred Brand $95.00$190.00P
ANADROL-50 TABLET   4 Non-Preferred Brand $95.00$190.00None
ANAFRANIL 25 MG 30 CAPSULE BOTTLE   4 Non-Preferred Brand $95.00$190.00None
ANAFRANIL 50 MG 30 CAPSULE BOTTLE   4 Non-Preferred Brand $95.00$190.00None
ANAFRANIL 75 MG 30 CAPSULE BOTTLE   4 Non-Preferred Brand $95.00$190.00None
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   2* Generic $15.00$30.00None
ANASTROZOLE 1 MG TABLET   2* Generic $15.00$30.00None
ANCOBON 250MG CAPSULE   5* Specialty Tier 25%25%None
ANCOBON 500MG CAPSULE   5* Specialty Tier 25%25%None
ANDRODERM 2 MG/24HR PATCH   3* Preferred Brand $42.00$84.00None
ANDRODERM 4 MG/24HR PATCH   3* Preferred Brand $42.00$84.00None
ANDROGEL 1.62% (1.25G) GEL PCKT   4 Non-Preferred Brand $95.00$190.00None
ANDROGEL 1.62% (2.5G) GEL PCKT   4 Non-Preferred Brand $95.00$190.00None
ANDROGEL 1% (50MG) GEL PACKET   4 Non-Preferred Brand $95.00$190.00None
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET   4 Non-Preferred Brand $95.00$190.00None
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDROID 10 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
Angeliq 0.25/0.5 28 Day Pack   4 Non-Preferred Brand $95.00$190.00None
ANGELIQ 1-0.5MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ANORO ELLIPTA 62.5-25 MCG INH   4 Non-Preferred Brand $95.00$190.00None
ANTABUSE 250MG TABLET   2* Generic $15.00$30.00None
ANTABUSE 500MG TABLET   2* Generic $15.00$30.00None
ANTARA 30 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
ANTARA 90 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
ANUSOL-HC 2.5% CREAM   2* Generic $15.00$30.00None
APEXICON E 0.05% CREAM   2* Generic $15.00$30.00None
APIDRA 100 UNITS/ML VIAL   4 Non-Preferred Brand $95.00$190.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APIDRA SOLOSTAR 100 UNITS/ML   4 Non-Preferred Brand $95.00$190.00None
APLENZIN ER 174 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
APLENZIN ER 348 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
APLENZIN ER 522 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
APOKYN 30 MG/3 ML CARTRIDGE   5* Specialty Tier 25%25%None
Apraclonidine 5 MG/ML Ophthalmic Solution   2* Generic $15.00$30.00None
APREPITANT 125 MG CAPSULE [Emend]   2* Generic $15.00$30.00P
APREPITANT 125-80-80 MG PACK [Emend]   2* Generic $15.00$30.00P
APREPITANT 40 MG CAPSULE [Emend]   2* Generic $15.00$30.00P
APREPITANT 80 MG CAPSULE [Emend]   2* Generic $15.00$30.00P
APRI 0.15-0.03 TABLET   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APRISO CP24   4 Non-Preferred Brand $95.00$190.00None
APTENSIO XR 10 MG CAPSULE   3* Preferred Brand $42.00$84.00None
APTENSIO XR 15 MG CAPSULE   3* Preferred Brand $42.00$84.00None
APTENSIO XR 20 MG CAPSULE   3* Preferred Brand $42.00$84.00None
APTENSIO XR 30 MG CAPSULE   3* Preferred Brand $42.00$84.00None
APTENSIO XR 40 MG CAPSULE   3* Preferred Brand $42.00$84.00None
APTENSIO XR 50 MG CAPSULE   3* Preferred Brand $42.00$84.00None
APTENSIO XR 60 MG CAPSULE   3* Preferred Brand $42.00$84.00None
APTIOM 200 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
APTIOM 400 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
APTIOM 600 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIOM 800 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
APTIVUS 250MG CAPSULE   3* Preferred Brand $42.00$84.00None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   3* Preferred Brand $42.00$84.00None
ARALAST NP 1,000 MG VIAL   5* Specialty Tier 25%25%None
ARANELLE 7-9-5 TABLET   2* Generic $15.00$30.00None
ARANESP 10 MCG/0.4 ML SYRINGE   4 Non-Preferred Brand $95.00$190.00P
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE   4 Non-Preferred Brand $95.00$190.00P
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Brand $95.00$190.00P
ARANESP 200MCG/0.4ML SYRINGE   4 Non-Preferred Brand $95.00$190.00P
ARANESP 200MCG/ML VIAL   4 Non-Preferred Brand $95.00$190.00P
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING   4 Non-Preferred Brand $95.00$190.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Brand $95.00$190.00P
ARANESP 300MCG/ML VIAL   4 Non-Preferred Brand $95.00$190.00P
ARANESP 500MCG/1ML SYRINGE   4 Non-Preferred Brand $95.00$190.00P
ARANESP 60MCG/ML VIAL   4 Non-Preferred Brand $95.00$190.00P
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE   4 Non-Preferred Brand $95.00$190.00P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   4 Non-Preferred Brand $95.00$190.00P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   4 Non-Preferred Brand $95.00$190.00P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Non-Preferred Brand $95.00$190.00P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Non-Preferred Brand $95.00$190.00P
ARAVA 10MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ARAVA 20MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARCALYST INJECTION 220MG/VIAL   5* Specialty Tier 25%25%None
ARCAPTA NEOHALER 75 MCG CAP   4 Non-Preferred Brand $95.00$190.00None
ARICEPT 10MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ARICEPT 23 MG TABLETS   4 Non-Preferred Brand $95.00$190.00None
ARICEPT 5MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ARIKAYCE 590 MG/8.4 ML VIAL-NEB   5* Specialty Tier 25%25%None
ARIMIDEX 1 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   2* Generic $15.00$30.00None
ARIPIPRAZOLE 10 MG TABLET [Abilify]   2* Generic $15.00$30.00None
ARIPIPRAZOLE 15 MG TABLET [Abilify]   2* Generic $15.00$30.00None
ARIPIPRAZOLE 2 MG TABLET [Abilify]   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 20 MG TABLET [Abilify]   2* Generic $15.00$30.00None
ARIPIPRAZOLE 30 MG TABLET [Abilify]   2* Generic $15.00$30.00None
ARIPIPRAZOLE 5 MG TABLET [Abilify]   2* Generic $15.00$30.00None
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   2* Generic $15.00$30.00None
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   2* Generic $15.00$30.00None
ARISTADA ER 1064 MG/3.9 ML SYR   5* Specialty Tier 25%25%None
ARISTADA ER 441 MG/1.6 ML SYRN   5* Specialty Tier 25%25%None
ARISTADA ER 662 MG/2.4 ML SYRN   5* Specialty Tier 25%25%None
ARISTADA ER 882 MG/3.2 ML SYRN   5* Specialty Tier 25%25%None
ARISTADA INITIO ER 675 MG/2.4 SUSER SYR   5* Specialty Tier 25%25%None
ARIXTRA 7.5 MG/0.6 ML SYRINGE   5* Specialty Tier 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Armodafinil 150 MG TABLET [NUVIGIL]   2* Generic $15.00$30.00P
Armodafinil 200 MG Oral Tablet [NUVIGIL]   2* Generic $15.00$30.00P
Armodafinil 250 MG TABLET [NUVIGIL]   2* Generic $15.00$30.00P
Armodafinil 50 MG TABLET [NUVIGIL]   2* Generic $15.00$30.00P
ARNUITY ELLIPTA 100 MCG INH   4 Non-Preferred Brand $95.00$190.00None
ARNUITY ELLIPTA 200 MCG INH   4 Non-Preferred Brand $95.00$190.00None
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   4 Non-Preferred Brand $95.00$190.00None
AROMASIN 25MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   4 Non-Preferred Brand $95.00$190.00None
ARTHROTEC 75 TABLET EC   4 Non-Preferred Brand $95.00$190.00None
ASACOL HD DR 800 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASCOMP WITH CODEINE CAPSULE   2* Generic $15.00$30.00None
ASHLYNA 0.15-0.03-0.01 MG TAB   2* Generic $15.00$30.00None
ASMANEX HFA 100 MCG INHALER   3* Preferred Brand $42.00$84.00None
ASMANEX HFA 200 MCG INHALER   3* Preferred Brand $42.00$84.00None
ASMANEX TWISTHALER 110 MCG #30   3* Preferred Brand $42.00$84.00None
ASMANEX TWISTHALER 220 MCG #30   4 Non-Preferred Brand $95.00$190.00None
ASMANEX TWISTHALER 220MCG #120   3* Preferred Brand $42.00$84.00None
ASMANEX TWISTHALER 220MCG #60   3* Preferred Brand $42.00$84.00None
Aspirin-Diphenhydramine ER 25-200 MG   2* Generic $15.00$30.00None
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE   2* Generic $15.00$30.00None
ASTAGRAF XL 0.5 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASTAGRAF XL 1 MG CAPSULE   4 Non-Preferred Brand $95.00$190.00P
ASTAGRAF XL 5 MG CAPSULE   5* Specialty Tier 25%25%P
ASTEPRO 0.15% NASAL SPRAY 30 ML   4 Non-Preferred Brand $95.00$190.00None
ATACAND 16 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ATACAND 32 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ATACAND 4 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ATACAND 8 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ATACAND HCT 16-12.5 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ATACAND HCT 32-12.5 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ATACAND HCT 32-25 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ATAZANAVIR SULFATE 150 MG CAP [Reyataz]   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATAZANAVIR SULFATE 200 MG CAP [Reyataz]   2* Generic $15.00$30.00None
ATAZANAVIR SULFATE 300 MG CAP [Reyataz]   2* Generic $15.00$30.00None
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK   4 Non-Preferred Brand $95.00$190.00None
ATENOLOL 100 MG TABLET   1* Preferred Generic $7.00$0.00None
ATENOLOL 25 MG TABLET   1* Preferred Generic $7.00$0.00None
ATENOLOL 50 MG TABLET   1* Preferred Generic $7.00$0.00None
ATENOLOL-CHLORTHALIDONE 100-25   2* Generic $15.00$30.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2* Generic $15.00$30.00None
ATIVAN 0.5 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ATIVAN 1 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ATIVAN 1 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATIVAN 2 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   2* Generic $15.00$30.00None
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   2* Generic $15.00$30.00None
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   2* Generic $15.00$30.00None
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   2* Generic $15.00$30.00None
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   2* Generic $15.00$30.00None
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   2* Generic $15.00$30.00None
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   2* Generic $15.00$30.00None
ATORVASTATIN 10 MG TABLET [Lipitor]   1* Preferred Generic $7.00$0.00None
ATORVASTATIN 20 MG TABLET [Lipitor]   1* Preferred Generic $7.00$0.00None
ATORVASTATIN 40 MG TABLET [Lipitor]   1* Preferred Generic $7.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATORVASTATIN 80 MG TABLET [Lipitor]   1* Preferred Generic $7.00$0.00None
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   2* Generic $15.00$30.00None
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   2* Generic $15.00$30.00None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   2* Generic $15.00$30.00None
ATRALIN 0.05% GEL   4 Non-Preferred Brand $95.00$190.00P
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand $95.00$190.00None
ATROPINE 1% EYE DROPS   2* Generic $15.00$30.00None
ATROVENT HFA AER 17MCG   3* Preferred Brand $42.00$84.00None
AUBAGIO 14 MG TABLET   5* Specialty Tier 25%25%P
AUBAGIO 7 MG TABLET   5* Specialty Tier 25%25%P
AUBRA-28 TABLET   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUGMENTIN 125-31.25 MG/5 ML   3* Preferred Brand $42.00$84.00None
AURYXIA 210 MG TABLET   4 Non-Preferred Brand $95.00$190.00P
AUSTEDO 12 MG TABLET   5* Specialty Tier 25%25%None
AUSTEDO 6 MG TABLET   5* Specialty Tier 25%25%None
AUSTEDO 9 MG TABLET   5* Specialty Tier 25%25%None
AUVI-Q 0.1 MG AUTO-INJECTOR   5* Specialty Tier 25%25%None
AUVI-Q 0.15 MG AUTO-INJECTOR   5* Specialty Tier 25%25%None
AUVI-Q 0.3 MG AUTO-INJECTOR   5* Specialty Tier 25%25%None
AVALIDE 150-12.5 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AVALIDE 300-12.5 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AVANDIA 2 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDIA 4 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AVAPRO 150 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AVAPRO 300 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AVAPRO 75 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AVC 15% CREAM   3* Preferred Brand $42.00$84.00None
AVEED 750 MG/3 ML VIAL   4 Non-Preferred Brand $95.00$190.00None
AVELOX 400 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AVIANE 0.1-0.02 TABLET   2* Generic $15.00$30.00None
AVITA 0.025% CREAM   2* Generic $15.00$30.00P
Avita 0.25mg/g 45 g in 1 TUBE   2* Generic $15.00$30.00P
AVODART 0.5 MG SOFTGEL   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVONEX ADMIN PACK 30 MCG VL   5* Specialty Tier 25%25%None
AVONEX PEN 30 MCG/0.5 ML KIT   5* Specialty Tier 25%25%None
AVONEX PREFILLED SYR 30 MCG KT   5* Specialty Tier 25%25%None
AVYCAZ 2.5 GRAM VIAL   4 Non-Preferred Brand $95.00$190.00None
Aygestin 5mg/1 50 TABLET BOTTLE   2* Generic $15.00$30.00None
AZASAN 100MG TABLET   2* Generic $15.00$30.00P
AZASAN 75MG TABLET   2* Generic $15.00$30.00P
AZASITE 1% EYE DROPS   4 Non-Preferred Brand $95.00$190.00None
AZATHIOPRINE 50 MG TABLET   2* Generic $15.00$30.00P
AZELAIC ACID 15% GEL [Finacea]   2* Generic $15.00$30.00None
AZELASTINE 0.15% NASAL SPRAY   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZELASTINE 137 MCG NASAL SPRAY   2* Generic $15.00$30.00None
AZELASTINE HCL 0.05% DROPS   2* Generic $15.00$30.00None
AZELEX 20% CREAM 30GM TUBE   3* Preferred Brand $42.00$84.00None
AZILECT 0.5MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AZILECT 1MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AZITHROMYCIN 1 GM PWD PACKET   3* Preferred Brand $42.00$84.00None
AZITHROMYCIN 100 MG/5 ML SUSP   2* Generic $15.00$30.00None
AZITHROMYCIN 200 MG/5 ML SUSP   2* Generic $15.00$30.00None
AZITHROMYCIN 250 MG TABLET   2* Generic $15.00$30.00None
AZITHROMYCIN 250 MG TABLET   2* Generic $15.00$30.00None
AZITHROMYCIN 500 MG TABLET   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2* Generic $15.00$30.00None
AZITHROMYCIN 600 MG TABLET   2* Generic $15.00$30.00None
AZITHROMYCIN I.V. 500 MG VIAL   2* Generic $15.00$30.00None
AZOPT 1% EYE DROPS   4 Non-Preferred Brand $95.00$190.00None
AZOR 10-20 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AZOR 10MG-40MG TABLET (30 CT)   4 Non-Preferred Brand $95.00$190.00None
AZOR 5-40 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AZOR 5MG-20MG TABLET (30 CT)   4 Non-Preferred Brand $95.00$190.00None
Aztreonam 1000 MG Injection [Azactam]   3* Preferred Brand $42.00$84.00None
Aztreonam 2000 MG Injection [Azactam]   3* Preferred Brand $42.00$84.00None
AZTREONAM FOR INJECTION   2* Generic $15.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZULFIDINE 500 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
AZULFIDINE ENTAB 500 MG   4 Non-Preferred Brand $95.00$190.00None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Kaiser Permanente Medicare Plus Std w/Part D (AB) (Cost) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $415 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2019 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.








Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.